11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention

Thissiteisintendedforhealthcareprofessionals

News&Perspective
Drugs&Diseases
CME&Education
Specialty:
Edition:ENGLISH
DEUTSCH
ESPAOL
FRANAIS
PORTUGUS
MyAccount:TIskandar
LogOut
Edition:ENGLISHDEUTSCHESPAOLFRANAISPORTUGUS
TIskandar

MyAccountLogOut

http://emedicine.medscape.com/article/152191treatment 1/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention

http://emedicine.medscape.com/article/152191treatment 2/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention

http://emedicine.medscape.com/article/152191treatment 3/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention

Search
NoResults

Search
NoResults

News&PerspectiveDrugs&DiseasesCME&Education
close
PleaseconfirmthatyouwouldliketologoutofMedscape.Ifyoulogout,youwillberequiredtoenteryourusernameand
passwordthenexttimeyouvisit.LogoutCancel

CardiogenicShockTreatment&Management
Author:Xiushui(Mike)Ren,MDChiefEditor:HenryHOoi,MD,MRCPImore...

Updated:Dec13,2015

ApproachConsiderations
Cardiogenicshockisanemergencyrequiringimmediateresuscitativetherapybefore
shockirreversiblydamagesvitalorgans.Thekeytoagoodoutcomeinpatientswith
cardiogenicshockisanorganizedapproach,withrapiddiagnosisandprompt
initiationofpharmacologictherapytomaintainbloodpressureandcardiacoutput
andrespiratorysupport,aswellasreversaloftheunderlyingcause.

Allpatientsrequireadmissiontoanintensivecaresetting,whichmayinvolve
emergenttransfertothecardiaccatheterizationsuite,criticalcaretransporttoa
tertiarycarecenter,orinternaltransfertotheintensivecareunit(ICU).

Earlyanddefinitiverestorationofcoronarybloodflowisthemostimportant
interventionforachievinganimprovedsurvivalrate.Atpresent,itrepresents
standardtherapyforpatientswithcardiogenicshockduetomyocardialischemia.

Correctionofelectrolyteandacidbaseabnormalities,suchashypokalemia,
hypomagnesemia,andacidosis,isessentialincardiogenicshock.

Cardiogenicshockmaybepreventedwithearlyrevascularizationinpatientswith
myocardialinfarction(MI)andwithrequiredinterventioninpatientswithstructural
heartdisease.

Procedures

Placementofacentrallinemayfacilitatevolumeresuscitation,providevascular
accessformultipleinfusions,andallowinvasivemonitoringofcentralvenous
pressure.Centralvenouspressuremayalsobeusedtoguidefluidresuscitation.

Althoughnotnecessaryforthediagnosisofcardiogenicshock,invasivemonitoring
withapulmonaryarterycathetermaybehelpfulinguidingfluidresuscitationin
situationsinwhichleftventricularpreloadisdifficulttodetermine.

Pulmonaryarterycatheterpressuremeasurementsmayalsobeusefulinprognosis.
RetrospectiveevaluationofthesemeasurementsfromtheSHOCKtrial

http://emedicine.medscape.com/article/152191treatment 4/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention
demonstratedthatstrokevolumeindex(SVI)andstrokeworkindex(SWI)vary
inverselywithmortality. [20]

Anarteriallinemaybeplacedtoprovidecontinuousbloodpressuremonitoring.
Thisisparticularlyusefulifthepatientrequiresinotropicmedications.

Anintraaorticballoonpumpmaybeplacedintheemergencydepartmentasa
bridgetopercutaneouscoronaryintervention(PCI)orcoronaryarterybypassgraft
(CABG),todecreasemyocardialworkloadandtoimproveendorganperfusion. [11]

PCIandcoronaryarterybypass

CliniciansshouldbealerttothefactthattheSHOCKtrialdemonstratedthateither
PCIorcoronaryarterybypassisthetreatmentofchoiceforcardiogenicshockand
thateachhasbeenshowntomarkedlydecreasemortalityratesat1year.PCI
shouldbeinitiatedwithin90minutesofpresentationhowever,itremainshelpful,
asanacuteintervention,within12hoursofpresentation.

Ifsuchafacilityisnotimmediatelyavailable,thrombolyticsshouldbeconsidered.
However,thistreatmentissecondbest.Anincreasedmortalityisseeninsituations
inwhichthrombolyticsareusedinsteadofPCI.Thisisduetotherelative
ineffectivenessofthethrombolyticmedicationstolyseclotsinlowbloodpressure
situations. [22,2]

Consultations

Consultacardiologistattheearliestopportunitybecausehisorherinsightand
expertisemaybeinvaluableforfacilitatingechocardiographicsupport,placementof
anintraaorticballoonpump(IABP),andtransfertomoredefinitivecare(eg,
cardiaccatheterizationsuite,ICU,operatingroom).Inseverecases,alsoconsider
discussingthecasewithacardiothoracicsurgeon.

Deterrenceandprevention

Althoughcardiogenicshockisnotentirelypreventable,measurescanbetakento
minimizetheriskofoccurrence,recognizeitatearlierstages,andbegincorrective
therapymoreexpeditiously.Deterrenceandpreventionrequireahighdegreeof
suspicionandheightenedawareness.

Careisrequiredintreatingpatientswithacutecoronarysyndromeswhoarenotyet
incardiogenicshock.CarefuluseofbetablockersandACEinhibitorsinthese
patientsisessentialtoavoidhypotensionleadingtocardiogenicshock. [2]

PrehospitalCare
Prehospitalcareisaimedatminimizinganyfurtherischemiaandshock.Allpatients
requireintravenousaccess,highflowoxygenadministeredbymask,andcardiac
monitoring.

Twelveleadelectrocardiographyperformedinthefieldbyappropriatelytrained
paramedicsmaybeusefulindecreasingdoortoPCItimesand/ortimetothe
administrationofthrombolyticsbecauseacuteSTsegmentelevationmyocardial
infarctions(STEMIs)canbeidentifiedearlier.Theemergencydepartment(ED)can
thusbealertedandmaymobilizetheappropriateresources.

Inotropicmedicationsshouldbeconsideredinsystemswithappropriatelytrained
paramedicalpersonnel.

Whenclinicallynecessary,positivepressureventilationandendotrachealintubation
shouldbeperformed.Continuouspositiveairwaypressure(CPAP)orbilevelpositive
airwaypressure(BiPAP)supportcanbeconsideredinappropriatelyequipped
systems.

Resuscitation,Ventilation,andPharmacologic
Intervention
Initialmanagementincludesfluidresuscitationtocorrecthypovolemiaand
hypotension,unlesspulmonaryedemaispresent.Centralvenousandarteriallines
areoftenrequired.SwanGanzcatheterizationandcontinuouspercutaneous
oximetryareroutine.

Oxygenationandairwayprotectionarecriticalintubationandmechanicalventilation
arecommonlyrequired.However,althoughpositivepressureventilationmay
improveoxygenation,itmayalsocompromisevenousreturn,preload,totheheart.
Inanyevent,thepatientshouldbetreatedwithhighflowoxygen.Studiesin
patientswithacutecardiogenicpulmonaryedemahaveshownnoninvasive
ventilationtoimprovehemodynamicsandreducetheintubationrate.Mortality,
however,isunaffected.

AstudybyShinetalsuggestedthatpatientswhoreceiveextracorporeal
cardiopulmonaryresuscitation(CPR)versusconventionalCPRforlongerthan10
minutesfollowinginhospitalarresthaveagreaterchanceofsurvival. [23]

Allpatientswithcardiogenicshockrequireclosehemodynamicmonitoring,volume
supporttoensureadequatesufficientpreload,andventilatorysupport.

Pharmacologictherapy

Patientswithmyocardialinfarction(MI)oracutecoronarysyndromearegiven
aspirinandheparin.Bothofthesemedicationshavebeenshowntobeeffectivein
reducingmortalityinseparatestudies.Beforeinitiatingtherapy,however,care
shouldbetakentoensurethatthepatientdoesnothaveamyocardialwallrupture
thatisamenabletosurgery.

http://emedicine.medscape.com/article/152191treatment 5/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention
Thereisnoneedtostartclopidogreluntilafterangiography,sinceangiographymay
demonstratethatthereisaneedforurgentcoronarybypass. [2]

TheglycoproteinIIb/IIIainhibitorsimprovetheoutcomeofpatientswithnonST
segmentelevationacutecoronarysyndrome(NSTACS).Theyhavebeenfoundto
reducerecurrentMIfollowingpercutaneouscoronaryintervention(PCI)andin
cardiogenicshock.

HemodynamicSupport
Dopamine,norepinephrine,andepinephrinearevasoconstrictingdrugsthathelpto
maintainadequatebloodpressureduringlifethreateninghypotensionandhelpto
preserveperfusionpressureforoptimizingflowinvariousorgans. [21]Themean
bloodpressurerequiredforadequatesplanchnicandrenalperfusion(meanarterial
pressure[MAP]of60or65mmHg)isbasedonclinicalindicesoforganfunction.

Inpatientswithinadequatetissueperfusionandadequateintravascularvolume,
initiationofinotropicand/orvasopressordrugtherapymaybenecessary.Dopamine
increasesmyocardialcontractilityandsupportsthebloodpressurehowever,itmay
increasemyocardialoxygendemand.Dobutaminemaybepreferableifthesystolic
bloodpressureishigherthan80mmHgithastheadvantageofnotaffecting
myocardialoxygendemandasmuchasdopaminedoes.However,theresulting
tachycardiamayprecludetheuseofthisinotropicagentinsome
patients.Dopaminewillcausemoretachycardiathandobutamineforany
correspondingincreaseincardiacoutput.

Dopamineisusuallyinitiatedatarateof510mcg/kg/minintravenously,andthe
infusionrateisadjustedaccordingtothebloodpressureandotherhemodynamic
parameters.Often,patientsmayrequirehighdosesofdopamine(asmuchas20
mcg/kg/min).

Ifthepatientremainshypotensivedespitemoderatedosesofdopamine,adirect
vasoconstrictor(eg,norepinephrine)shouldbestartedatadoseof0.5mcg/kg/min
andtitratedtomaintainanMAPof60mmHg.Thepotentvasoconstrictors(eg,
norepinephrine)arebestreservedforsituationsofrefractoryhypotensionandorgan
hypoperfusion,duetotheirunfavorableroleinincreasingafterloadandcardiac
fillingpressureand,consequently,impairingcardiacoutput.However,onestudy
showedtherewasnodifferenceinoutcomesinpatientswithshockwhentreated
withnorepinephrineversusdopamine. [24]Thereisnoconsensusregardingfirstline
choiceofvasopressorincardiogenicshock.

Vasopressorsupportivetherapy

Thefollowingisabriefreviewofthemechanismofactionandindicationsfordrugs
usedforhemodynamicsupportofcardiogenicshock. [25,26]Thereislittle
randomizedclinicaltrialdatatoguidetheuseofinotropicorpressortherapyin
patientswithcardiogenicshock.Theiruseisindicatedinpatientswithcardiogenic
shock,butitisimportanttonotethatasurvivalbenefitfromtheseagentshasnot
beenestablished.Indeed,routineuseoftheseagentsinpatientswith
hemodynamicallystable,decompensatedheartfailurewasassociatedwithgreater
morbidityandnoclinicalbenefit(OutcomesofaProspectiveTrialofIntravenous
MilrinoneforExacerbationsofChronicHeartFailure[OPTIMECHF]). [27,28]

Dopamine

Dopamineisaprecursorofnorepinephrineandepinephrineandhasvaryingeffects
accordingtothedosesinfused.Adoseoflessthan5mcg/kg/mincauses
vasodilationofrenal,mesenteric,andcoronarybeds.Atadoseof510mcg/kg/min,
beta1adrenergiceffectsinduceanincreaseincardiaccontractilityandheartrate.

Atdosesgreater10mcg/kg/min,predominantalphaadrenergiceffectsleadto
arterialvasoconstrictionandanelevationinbloodpressure.Thebloodpressure
increasesprimarilyasaresultofitsinotropiceffect.Theundesirableeffectsare
tachycardiaandincreasedpulmonaryshunting,aswellasthepotentialfor
decreasedsplanchnicperfusionandincreasedpulmonaryarterialwedgepressure.

Norepinephrine

Norepinephrineisapotentalphaadrenergicagonistwithonlyminorbeta1
adrenergicagonisteffects.Norepinephrinecanincreasebloodpressuresuccessfully
inpatientswhoremainhypotensivefollowingdopamine.Thedoseof
norepinephrinemayvaryfrom0.21.5mcg/kg/min,andlargedoses,ashighas3.3
mcg/kg/min,havebeenusedbecauseofthealphareceptordownregulationin
personswithsepsis.

Epinephrine

Epinephrineisanagonistofalpha1,beta1,andbeta2receptors.Itcanincreasethe
MAPbyincreasingthecardiacindexandstrokevolume,aswellassystemic
vascularresistance(SVR)andheartrate.Epinephrinedecreasesthesplanchnic
bloodflowandmayincreaseoxygendeliveryandconsumption.

Administrationofthisagentmaybeassociatedwithanincreaseinsystemicand
regionallactateconcentrations.Theuseofepinephrineisrecommendedonlyin
patientswhoareunresponsivetotraditionalagents.Otherundesirableeffects
includeanincreaseinlactateconcentration,apotentialtoproducemyocardial
ischemia,thedevelopmentofarrhythmias,andareductioninsplanchnicflow.

Levosimendan

Levosimendan,widelyusedinEuropebutnotapprovedforuseintheUnited
States,canbeconsideredforuseinconjunctionwithvasopressorstoimprove
coronarybloodflow. [29,30]Thisagentactsbyincreasingthesensitivityofthe
cardiacmyofilamenttocalcium,ratherthanincreasingintracellularconcentrationsof
freecalcium.LevosimendanstabilisestroponinCandthekineticsofactinmyosin
crossbridgeswithoutincreasingmyocardialconsumptionofadenosinetriphosphate

http://emedicine.medscape.com/article/152191treatment 6/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention
(ATP).Levosimendanisapotentinotropeandalsoavasodilatorofthearterial,
venous,andcoronarycirculation.Itshouldbeusedwithcaution,however,asitcan
causehypotension.

Inotropicsupportivetherapy

Dobutamine

Dobutamine(sympathomimeticagent)isabeta1receptoragonist,althoughithas
somebeta2receptorandminimalalphareceptoractivity.Itisusedinadoserange
of2to20mcg/kg/minandhasahalflifeofapproximately2minutes.Intravenous
dobutamineinducessignificantpositiveinotropiceffects,withmildchronotropic
effectsthroughactivationofadenylcyclase,anincreaseinintracellularcyclic
adenosinemonophosphate(cAMP)and,therefore,calciumlevels.Italsoinduces
mildperipheralvasodilation(decreaseinafterload).Thecombinedeffectof
increasedinotropyanddecreasedafterloadinducesasignificantincreaseincardiac
output.

Inthesettingofacutemyocardialinfarction(MI),dobutamineusecouldincrease
thesizeoftheinfarctbecauseoftheincreaseinmyocardialoxygenconsumption
thatmayensue.Ingeneral,cautionshouldbeexercisedwhenadministering
dobutamineinpatientswithmoderateorseverehypotension(eg,systolicblood
pressure<80mmHg),becausetheperipheralvasodilation,insomecases,may
causeafurtherfallinbloodpressure.

PhosphodiesteraseIIIinhibitors

PhosphodiesteraseIIIinhibitors(PDIs),whichincludeinamrinone(formerly
amrinone)andmilrinone,areinotropicagentswithvasodilatingpropertiesandlong
halflives.Milrinoneisusedinadoserangeof0.3to0.75mcg/kg/min,andhasa
longhalflifeof1.5to3hours,withthelongerhalflifeinpatientswithrenal
impairment.

ThemechanismofactionofPDIsisdistinctfromdobutamineinthattheyprevent
breakdownofcAMP,therebyincreasingintracellularcAMPlevels.The
hemodynamicpropertiesofPDIsare(1)apositiveinotropiceffectonthe
myocardiumandperipheralvasodilation(decreasedafterload)and(2)areductionin
pulmonaryvascularresistance(decreasedpreload).

PDIsmaybebeneficialinpersonswithcardiacpumpfailurewhorequiremore
concomitantpulmonaryandsystemicvasodilationthanistypicallyachievedby
dobutamine.Unlikecatecholamineinotropes,thesedrugsarenotdependenton
adrenoreceptoractivitytherefore,patientsarelesslikelytodeveloptoleranceto
thesemedications.

PDIsarelesslikelythancatecholaminestocauseadverseeffectsknowntobe
associatedwithadrenoreceptoractivity(eg,increasedmyocardialoxygendemand,
myocardialischemia).Theyarealsoassociatedwithlesstachycardiaand
myocardialoxygenconsumption.However,theincidenceoftachyarrhythmiasis
greaterwithPDIsthanwithdobutamine.

ThrombolyticTherapy
Althoughthrombolytictherapy(TT)reducesmortalityratesinpatientswithacute
myocardialinfarction(MI),itsbenefitsforpatientswithcardiogenicshocksecondary
toMIaredisappointing.WhenusedearlyinthecourseofMI,TTreducesthe
likelihoodofsubsequentdevelopmentofcardiogenicshockaftertheinitialevent.

IntheGruppoItalianoPerloStudioDellaStreptokinaseNell'InfartoMiocardiotrial,
30daymortalityrateswere69.9%inpatientswithcardiogenicshockwhoreceived
streptokinase,comparedto70.1%inpatientswhoreceivedaplacebo. [31,32]

Similarly,otherstudiesemployingatissueplasminogenactivatordidnotshow
reductionsinmortalityratesfromcardiogenicshock.Lowerratesofreperfusionof
theinfarctrelatedarteryinpatientswithcardiogenicshockmayhelptoexplainthe
disappointingresultsfromTT.OtherreasonsforthedecreasedefficacyofTTare
theexistenceofhemodynamic,mechanical,andmetaboliccausesofcardiogenic
shockthatareunaffectedbyTT.

ThrombolytictherapyplusIABP

Aprospectivecohortstudydemonstratedthepotentialsurvivalbenefitofcombining
TTwithintraaorticballoonpump(IABP)counterpulsationinpatientswithMI
complicatedbycardiogenicshock. [33]Ofthe1190patientsenrolled,thetreatments
were(1)noTTandnoIABPcounterpulsation(33%,n=285),(2)IABP
counterpulsationonly(33%,n=279),(3)TTonly(15%,n=132),and(4)TTand
IABPcounterpulsation(19%,n=160).

PatientsincardiogenicshockwhoweretreatedwithTThadlowerinhospital
mortalityratesthandidthosewhodidnotreceiveTT(54%vs64%),andpatients
selectedforIABPcounterpulsationhadlowerinhospitalmortalityratesthandid
thosewhodidnotreceiveIABPcounterpulsation(50%vs72%). [33]Furthermore,a
significantdifferencewasnotedforinhospitalmortalityratesamongthe4treatment
groupsthatis,TTplusIABPcounterpulsation(47%),IABPcounterpulsationonly
(52%),TTonly(63%),noTTandnoIABPcounterpulsation
(77%).Revascularizationinfluencedinhospitalmortalityratessignificantly(39%
withrevascularizationvs78%withoutrevascularization). [33]

Patientswhoareunsuitableforinvasivetherapyshouldbetreatedwitha
thrombolyticagentintheabsenceofcontraindications.ThisisaclassI
recommendationbyAmericanCollegeofCardiology(ACC)/AmericanHeart
Association(AHA)guidelines. [21]

IntraAorticBalloonPump

http://emedicine.medscape.com/article/152191treatment 7/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention
Theuseoftheintraaorticballoonpump(IABP)reducessystolicleftventricular
afterloadandaugmentsdiastoliccoronaryperfusionpressure,therebyincreasing
cardiacoutputandimprovingcoronaryarterybloodflow.TheIABPiseffectivefor
theinitialstabilizationofpatientswithcardiogenicshock.However,anIABPisnot
definitivetherapytheIABPstabilizespatientssothatdefinitivediagnosticand
therapeuticinterventionscanbeperformed. [34,35]

TheIABPalsomaybeausefuladjuncttothrombolysisinacutemyocardial
infarction(MI)forinitialstabilizationandtransferofpatientstoatertiarycare
facility.SomestudieshaveshownlowermortalityratesinpatientswithMIand
cardiogenicshocktreatedwithanIABPandsubsequentrevascularization. [33,36]

Complicationsmaybedocumentedinupto30%ofpatientswhoundergoIABP
therapytheserelateprimarilytolocalvascularproblems,embolism,infection,and
hemolysis.

TheimpactoftreatmentwithanIABPonlongtermsurvivaliscontroversialand
dependsonthepatientshemodynamicstatusandtheetiologyofthecardiogenic
shock.PatientselectionisthekeyissueinsertingtheIABPearly,ratherthan
waitinguntilfullblowncardiogenicshockhasdeveloped,mayresultinclinical
benefit.

Ramanathanetalfoundthatrapidandcompletereversalofsystemichypoperfusion
withIABPcounterpulsationintheSHOCKtrialandSHOCKregistrywas
independentlyassociatedwithimprovedinhospital,30day,and1yearsurvival,
regardlessofearlyrevascularization.Thissuggeststhatcompletereversalof
systemichypoperfusionwithIABPcounterpulsationisanimportantearlyprognostic
feature. [37]

IntheIABPSHOCKIIstudy,600patientswithcardiogenicshockcomplicating
acutemyocardialinfarctionwererandomizedtointraaorticballooncounterpulsation
ornointraaorticballooncounterpulsation.Allpatientswereexpectedtoundergo
earlyrevascularization.Useofintraaorticballooncounterpulsationdidnot
significantlyreduce30daymortalityinthesepatients. [38]

VentricularAssistDevices
Inrelativelyrecentyears,leftventricularassistdevices(LVADs)capableofproviding
completeshorttermhemodynamicsupporthavebeendeveloped.Theapplication
ofLVADduringreperfusion,afteracutecoronaryocclusion,causesreductionofthe
leftventricularpreload,increasesregionalmyocardialbloodflowandlactate
extraction,andimprovesgeneralcardiacfunction.TheLVADmakesitpossibleto
maintainthecollateralbloodflowasaresultofmaintainingthecardiacoutputand
aorticpressure,keepingwalltensionlowandreducingtheextentofmicrovascular
reperfusioninjury. [34,35,39]

Apooledanalysisfrom17studiesshowedthatthemeanageofthisgroupof
patientswithLVADswas59.54.5yearsandthatmeansupportdurationwas
146.260.2hours.In78.5%ofpatients(range,53.8100%),adjunctivereperfusion
therapy,mainlypercutaneoustransluminalcoronaryangioplasty(PTCA),wasused.
Meanweaningandsurvivalrateswere58.5%(range,4675%)and40%(range,29
58%),respectively. [34]

Inanycase,comparingstudiesisdifficultbecauseimportantdataareusually
missing,meanageofpatientsweredifferent,andtimetotreatmentisnot
standardized.Hemodynamicpresentationseemstobeworsecomparedwithdata
reportedintheSHOCKtrial,withlowercardiacindex,lowersystolicaorticpressure,
andhigherserumlactates.Takingtheseconsiderationsintoaccount,LVADsupport
seemstogivenosurvivalimprovementinpatientswithcardiogenicshock
complicatingacutemyocardialinfarction(MI),comparedwithearlyreperfusion
aloneorincombinationwithIABP.

Inarandomized,controlledtrialinwhich129patientswithendstageheartfailure
whowereineligibleforcardiactransplantationwereassignedeithertoreceivean
LVAD(68patients)ortoundergooptimalmedicalmanagement,survivalrateswere
higherintheLVADgroup.Theratesofsurvivalat1yearwere52%inthedevice
groupand25%inthemedicaltherapygroup,whiletheratesat2yearswere23%
and8%,respectively.Inaddition,thequalityoflifewassignificantlyimprovedat1
yearinthedevicegroup. [40]

ImplantableLVADsarebeingusedasabridgetohearttransplantationforpatients
withacuteMIandcardiogenicshock. [41]AccordingtotheHeartMateData
Registry[42],from19861998,41patients(5%ofthetotalnumberofHeartMateIP
patients)weresupportedwiththisimplantablepneumaticdeviceforacuteMI,and
25(61%)weresuccessfullybridgedtohearttransplantation.(Seeanexampleofan
LVADbelow.)

http://emedicine.medscape.com/article/152191treatment 8/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention

HeartMateIILeftVentricularAssistDevice.ReprintedwiththepermissionofThoratec
Corporation.

However,LVADsasabridgingoptionforpatientswithcardiogenicshockmustbe
consideredcautiouslyandmustbeavoidedinpatientswhoareunlikelytosurviveor
arenotlikelytobetransplantcandidates.Furtherinvestigationsarerequiredto
betterdefineindications,supportmodalities,andoutcomes.

Theindicationsforinsertionofaventricularassistdevicearecontroversial.Suchan
aggressiveapproachtosupportthecirculatorysystemincardiogenicshockis
appropriate(1)afterthefailureofmedicaltreatmentandanIABP,(2)whenthe
causeofcardiogenicshockispotentiallyreversible,or(3)ifthedevicecanbeused
asabridgingoption.

PercutaneousTransluminalCoronaryAngioplasty
Theretrospectiveandprospectivedatafavoraggressivemechanical
revascularizationinpatientswithcardiogenicshocksecondarytomyocardial
infarction(MI).

Reestablishingbloodflowintheinfarctrelatedarterymayimproveleftventricular
functionandsurvivalfollowingMI.InacuteMI,studiesshowthatpercutaneous
transluminalcoronaryangioplasty(PTCA)canachieveadequateflowin8090%of
patients,comparedwith5060%ofpatientsafterthrombolytictherapy(TT).

Severalretrospectiveclinicaltrialshaveshownthatpatientswithcardiogenicshock
duetomyocardialischemiabenefitted(reductionin30daymortalityrates)when
treatedwithangioplasty.Astudyofdirect(primary)PTCAinpatientswith
cardiogenicshockreportedlowermortalityratesinpatientstreatedwithangioplasty
combinedwiththeuseofstentsthaninpatientstreatwithmedicaltherapy. [43]

AstudybyAntoniuccietalfoundthatmortalityratesincreaseinrelationtothe
lengthoftimetotreatmentinpatientswithacuteMIwhoarenotconsideredtobe
atlowrisk. [44]Tostudytherelationshipoftimetotreatmentandmortalityin
patientswithacuteMI,aseriesof1336patientswhounderwentsuccessfulprimary
PTCAwerestratifiedintolowriskandnotlowriskpatientgroups.The6month
mortalityratewas9.3%fornotlowriskpatientsand1.3%forthelowriskpatients.
Anincreaseinthemortalityratefrom4.8%to12.9%withincreasingtimeto
reperfusionwasobservedinthenotlowriskgroup.Adelayfromsymptomonsetto
treatmentresultedinhighermortalityratesforthenotlowriskpatients. [44]

UsingprospectivedatafromtheBritishCardiovascularInterventionSociety(BCIS)
PCIdatabasethatevaluateddatafrom6,489EnglishandWelshpatients
undergoingPCIforacutecoronarysyndromeinthesettingofcardiogenic
shock,Kunadianetalreportedmortalityratesof37.3%at30days,40.0%at90
days,and44.3%at1year. [16]

CoronaryArteryBypassGrafting
Criticalleftmainarterydiseaseand3vesselcoronaryarterydiseasearecommon
findingsinpatientswhodevelopcardiogenicshock.Thepotentialcontributionof
ischemiainthenoninfarctedzonecontributestothedeteriorationofalready
compromisedmyocardialfunction.

Coronaryarterybypassgrafting(CABG)inthesettingofcardiogenicshockis
generallyassociatedwithhighsurgicalmorbidityandmortalityrates.Becausethe
resultsofpercutaneousinterventionscanbefavorable,routinebypasssurgeryis
oftendiscouragedforthesepatients.

A2004taskforceoftheAmericanCollegeofCardiology(ACC)andtheAmerican
HeartAssociation(AHA)gaveaclassIrecommendationtotheperformanceof
primarypercutaneouscoronaryintervention(PCI)oremergentCABGinpatients
youngerthan75yearswhohaveSTelevationmyocardialinfarction(STEMI)who
developshockwithin36hoursofMIandcanbetreatedwithin18hoursofshock
onset.PerformanceofprimaryPCIoremergentCABGwasconsideredreasonable
inpatientsolderthan75years(classIIarecommendation). [45]

RevascularizationintheSHOCKTrial

http://emedicine.medscape.com/article/152191treatment 9/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention
ResultsfromtheSHOCK(SHouldweemergentlyrevascularizeOccluded
CoronariesincardiogenicshocK)trialsupportedthesuperiorityofastrategythat
combinesearlyrevascularizationwithmedicalmanagementinpatientswith
cardiogenicshock. [22,43,46]Inthestudy,patientswereassignedtoreceiveeither
optimalmedicalmanagement,includinganintraaorticballoonpump(IABP)and
thrombolytictherapy(TT),orcardiaccatheterizationfollowedbyrevascularization
usingpercutaneoustransluminalcoronaryangioplasty(PTCA)orcoronaryartery
bypassgraft(CABG).

Themortalityratesat30dayswere46.7%intheearlyinterventiongroupand56%
inpatientstreatedwithoptimalmedicalmanagement.Althoughthese30day
resultsdidnotreachstatisticalsignificance,themortalityrateat6monthswas
significantlylowerintheearlyinterventiongroup(50.3%vs63.1%). [43]

The1yearsurvivalrateswerealsoreportedfromtheSHOCKtrial. [22]Thesurvival
rateat1yearwas46.7%forpatientsintheearlyrevascularizationgroupand33.6%
intheconservativemanagementgroup.Thetreatmentbenefitwasapparentonly
forpatientsyoungerthan75years(51.6%survivalrateinearlyrevascularization
groupvs33.3%inpatientstreatedwithoptimalmedicalmanagement).

Basedontheoutcomeofthisstudy,therecommendationisthatpatientswithacute
myocardialinfarction(MI)complicatedbycardiogenicshock,particularlythose
youngerthan75years,shouldberapidlytransferredtoacenterwithpersonnel
capableofperformingearlyangiographyandrevascularizationprocedures. [47]Long
termfollowupwasconductedannuallyuntil2005.Astrategyofearly
revascularizationresultedina13.2%absoluteand67%relativeimprovementin6
yearsurvivalcomparedwithinitialmedicaltherapy. [48]

PatientTransfer
Immediatelytransferapatientwhodevelopscardiogenicshocktoaninstitutionat
whichinvasivemonitoring,coronaryrevascularization,andskilledpersonnelare
availabletoprovideexpertcare.

Patientswithcardiogenicshockwhoareadmittedtoahospitalwithoutfacilitiesfor
revascularizationshouldbeimmediatelytransferredtoatertiarycarecenterwith
suchfacilities.IftimetoPCIismorethan1hourandonsetofsymptomshasbeen
within3hours,rapidadministrationofTTisrecommended.

Itshouldbekeptinmind,however,thatattemptstotransferapatientwith
cardiogenicshockmustbemadeonlywheneverythingpossiblehasbeendoneto
stabilizehisorherconditionandwhenthelevelofcareduringthetransferwillnot
significantlydecrease.

Medication

ContributorInformationandDisclosures
Author
Xiushui(Mike)Ren,MDCardiologist,ThePermanenteMedicalGroupAssociateDirectorofResearch,
CardiovascularDiseasesFellowship,CaliforniaPacificMedicalCenter

Xiushui(Mike)Ren,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollege
ofCardiology,AmericanSocietyofEchocardiography

Disclosure:Nothingtodisclose.

Coauthor(s)
AndrewLenneman

Disclosure:Nothingtodisclose.

ChiefEditor
HenryHOoi,MD,MRCPIDirector,AdvancedHeartFailureandCardiacTransplantProgram,Nashville
VeteransAffairsMedicalCenterAssistantProfessorofMedicine,VanderbiltUniversitySchoolofMedicine

Disclosure:Nothingtodisclose.

Acknowledgements
EthanSBrandler,MD,MPHClinicalAssistantProfessor,AttendingPhysician,DepartmentsofEmergency
MedicineandInternalMedicine,UniversityHospitalofBrooklyn,KingsCountyHospital

EthanSBrandler,MD,MPHisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
PhysiciansandSocietyforAcademicEmergencyMedicine

Disclosure:Nothingtodisclose.

DavidFMBrown,MDAssociateProfessor,DivisionofEmergencyMedicine,HarvardMedicalSchoolVice
Chair,DepartmentofEmergencyMedicine,MassachusettsGeneralHospital

DavidFMBrown,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
PhysiciansandSocietyforAcademicEmergencyMedicine

Disclosure:Nothingtodisclose.

DanielJDire,MD,FACEP,FAAP,FAAEMClinicalProfessor,DepartmentofEmergencyMedicine,Universityof
TexasMedicalSchoolatHoustonClinicalProfessor,DepartmentofPediatrics,UniversityofTexasHealth
SciencesCenterSanAntonio

DanielJDire,MD,FACEP,FAAP,FAAEMisamemberofthefollowingmedicalsocieties:AmericanAcademy
ofClinicalToxicology,AmericanAcademyofEmergencyMedicine,AmericanAcademyofPediatrics,American
CollegeofEmergencyPhysicians,andAssociationofMilitarySurgeonsoftheUS

Disclosure:Nothingtodisclose.

MarkAHostetler,MD,MPHAssociateProfessorofPediatrics,UniversityofChicagoChief,Sectionof
EmergencyMedicine,DepartmentofPediatrics,MedicalDirectorofPediatricEmergencyDepartment,University
ofChicagoChildren'sHospital
http://emedicine.medscape.com/article/152191treatment 10/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention
Disclosure:Nothingtodisclose.

AAntoineKazziMD,DeputyChiefofStaff,AmericanUniversityofBeirutMedicalCenterAssociateProfessor,
DepartmentofEmergencyMedicine,AmericanUniversityofBeirut,Lebanon

AAntoineKazziisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine

Disclosure:Nothingtodisclose.

RussellFKellyMD,AssistantProfessor,DepartmentofInternalMedicine,RushMedicalCollegeChairmanof
AdultCardiologyandDirectoroftheFellowshipProgram,CookCountyHospital

RussellFKellyisamemberofthefollowingmedicalsocieties:AmericanCollegeofCardiology

Disclosure:Nothingtodisclose.

RonaldJOudiz,MD,FACP,FACC,FCCPProfessorofMedicine,UniversityofCalifornia,LosAngeles,David
GeffenSchoolofMedicineDirector,LiuCenterforPulmonaryHypertension,DivisionofCardiology,LA
BiomedicalResearchInstituteatHarborUCLAMedicalCenter

RonaldJOudiz,MD,FACP,FACC,FCCPisamemberofthefollowingmedicalsocieties:AmericanCollegeof
Cardiology,AmericanCollegeofChestPhysicians,AmericanCollegeofPhysicians,AmericanHeartAssociation,
andAmericanThoracicSociety

Disclosure:ActelionGrant/researchfundsClinicalTrials+honorariaEncysiveGrant/researchfundsClinicalTrials
+honorariaGileadGrant/researchfundsClinicalTrials+honorariaPfizerGrant/researchfundsClinicalTrials+
honorariaUnitedTherapeuticsGrant/researchfundsClinicalTrials+honorariaLillyGrant/researchfundsClinical
Trials+honorariaLungRxClinicalTrials+honorariaBayerGrant/researchfundsConsulting

SatSharma,MD,FRCPCProfessorandHead,DivisionofPulmonaryMedicine,DepartmentofInternal
Medicine,UniversityofManitobaSiteDirector,RespiratoryMedicine,StBonifaceGeneralHospital

SatSharma,MD,FRCPCisamemberofthefollowingmedicalsocieties:AmericanAcademyofSleep
Medicine,AmericanCollegeofChestPhysicians,AmericanCollegeofPhysiciansAmericanSocietyofInternal
Medicine,AmericanThoracicSociety,CanadianMedicalAssociation,RoyalCollegeofPhysiciansandSurgeons
ofCanada,RoyalSocietyofMedicine,SocietyofCriticalCareMedicine,andWorldMedicalAssociation

Disclosure:Nothingtodisclose.

RichardHSinert,DOAssociateProfessorofEmergencyMedicine,ClinicalAssistantProfessorofMedicine,
ResearchDirector,StateUniversityofNewYorkCollegeofMedicineConsultingStaff,Departmentof
EmergencyMedicine,KingsCountyHospitalCenter

RichardHSinert,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysiciansand
SocietyforAcademicEmergencyMedicine

Disclosure:Nothingtodisclose.

FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:MedscapeSalaryEmployment

References

1.AlonsoDR,ScheidtS,PostM,KillipT.Pathophysiologyofcardiogenicshock.Quantificationofmyocardial
necrosis,clinical,pathologicandelectrocardiographiccorrelations.Circulation.1973Sep.48(3):58896.
[Medline].

2.ReynoldsHR,HochmanJS.Cardiogenicshock:currentconceptsandimprovingoutcomes.Circulation.
2008Feb5.117(5):68697.[Medline].

3.FunaroS,LaTorreG,MadonnaM,etal,fortheAMICIInvestigators.Incidence,determinants,and
prognosticvalueofreverseleftventricularremodellingafterprimarypercutaneouscoronaryintervention:
resultsoftheAcuteMyocardialInfarctionContrastImaging(AMICI)multicenterstudy.EurHeartJ.2009
Mar.30(5):56675.[Medline].

4.ForresterJS,WyattHL,DaLuzPL,TybergJV,DiamondGA,SwanHJ.Functionalsignificanceofregional
ischemiccontractionabnormalities.Circulation.1976Jul.54(1):6470.[Medline].

5.BeyersdorfF,BuckbergGD,AcarC,etal.Cardiogenicshockafteracutecoronaryocclusion.Pathogenesis,
earlydiagnosis,andtreatment.ThoracCardiovascSurg.1989Feb.37(1):2836.[Medline].

6.AlReesiA,AlZadjaliN,PerryJ,etal.Dobetablockersreduceshorttermmortalityfollowingacute
myocardialinfarction?Asystematicreviewandmetaanalysis.CJEM.2008May.10(3):21523.[Medline].

7.ChenZM,PanHC,ChenYP,etal.Earlyintravenousthenoralmetoprololin45,852patientswithacute
myocardialinfarction:randomisedplacebocontrolledtrial.Lancet.2005Nov5.366(9497):162232.
[Medline].

8.KolteD,KheraS,AronowWS,etal.Trendsinincidence,management,andoutcomesofcardiogenic
shockcomplicatingSTelevationmyocardialinfarctionintheUnitedStates.JAmHeartAssoc.2014Jan
13.3(1):e000590.[Medline].

9.GoldbergRJ,SamadNA,YarzebskiJ,GurwitzJ,BigelowC,GoreJM.Temporaltrendsincardiogenic
shockcomplicatingacutemyocardialinfarction.NEnglJMed.1999Apr15.340(15):11628.[Medline].

10.RoffiM,PatronoC,ColletJP,etal,fortheEuropeanSocietyofCardiologyTaskForce.2015ESC
GuidelinesforthemanagementofacutecoronarysyndromesinpatientspresentingwithoutpersistentST
segmentelevation:TaskForcefortheManagementofAcuteCoronarySyndromesinPatientsPresenting
withoutPersistentSTSegmentElevationoftheEuropeanSocietyofCardiology(ESC).EurHeartJ.2015
Aug29.[Medline].

11.GrafT,DeschS,EitelI,ThieleH.Acutemyocardialinfarctionandcardiogenicshock:pharmacologicand
mechanicalhemodynamicsupportpathways.CoronArteryDis.2015Sep.26(6):53544.[Medline].

12.BabaevA,FrederickPD,PastaDJ,EveryN,SichrovskyT,HochmanJS.Trendsinmanagementand
outcomesofpatientswithacutemyocardialinfarctioncomplicatedbycardiogenicshock.JAMA.2005Jul
27.294(4):44854.[Medline].

http://emedicine.medscape.com/article/152191treatment 11/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention
13.FoxKA,StegPG,EagleKA,GoodmanSG,AndersonFAJr,GrangerCB,etal.Declineinratesofdeath
andheartfailureinacutecoronarysyndromes,19992006.JAMA.2007May2.297(17):1892900.
[Medline].

14.JegerRV,RadovanovicD,HunzikerPR,PfistererME,StaufferJC,ErneP,etal.Tenyeartrendsinthe
incidenceandtreatmentofcardiogenicshock.AnnInternMed.2008Nov4.149(9):61826.[Medline].

15.AmsterdamEA,WengerNK,BrindisRG,etal,fortheACC,AHATaskForceonPracticeGuidelines,et
al.2014AHA/ACCguidelineforthemanagementofpatientswithnonSTelevationacutecoronary
syndromes:areportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceon
PracticeGuidelines.JAmCollCardiol.2014Dec23.64(24):e139228.[Medline].

16.KunadianV,QiuW,LudmanP,etal,fortheNationalInstituteforCardiovascularOutcomesResearch.
Outcomesinpatientswithcardiogenicshockfollowingpercutaneouscoronaryinterventioninthe
contemporaryera:ananalysisfromtheBCISdatabase(BritishCardiovascularInterventionSociety).JACC
CardiovascInterv.2014Dec.7(12):137485.[Medline].

17.HamonM,AgostiniD,LePageO,RiddellJW,HamonM.Prognosticimpactofrightventricular
involvementinpatientswithacutemyocardialinfarction:metaanalysis.CritCareMed.2008Jul.
36(7):202333.[Medline].

18.HasdaiD,CaliffRM,ThompsonTD,HochmanJS,OhmanEM,PfistererM,etal.Predictorsofcardiogenic
shockafterthrombolytictherapyforacutemyocardialinfarction.JAmCollCardiol.2000Jan.35(1):13643.
[Medline].

19.PicardMH,DavidoffR,SleeperLA,andtheSHOCKTrialinvestigators.SHouldweemergently
revascularizeOccludedCoronariesforcardiogenicshocK.Echocardiographicpredictorsofsurvivaland
responsetoearlyrevascularizationincardiogenicshock.Circulation.2003Jan21.107(2):27984.
[Medline].

20.JegerRV,LoweAM,BullerCE,PfistererME,DzavikV,WebbJG,etal.Hemodynamicparametersare
prognosticallyimportantincardiogenicshockbutsimilarfollowingearlyrevascularizationorinitialmedical
stabilization:areportfromtheSHOCKTrial.Chest.2007Dec.132(6):1794803.[Medline].

21.O'GaraPT,KushnerFG,AscheimDD,etal,fortheAmericanCollegeofCardiologyFoundation/American
HeartAssociationTaskForceonPracticeGuidelines.2013ACCF/AHAguidelineforthemanagementof
STelevationmyocardialinfarction:areportoftheAmericanCollegeofCardiologyFoundation/American
HeartAssociationTaskForceonPracticeGuidelines.Circulation.2013Jan29.127(4):e362425.
[Medline].

22.HochmanJS,SleeperLA,WhiteHD,DzavikV,WongSC,MenonV,etal.Oneyearsurvivalfollowing
earlyrevascularizationforcardiogenicshock.JAMA.2001Jan10.285(2):1902.[Medline].

23.ShinTG,ChoiJH,JoIJ,SimMS,SongHG,JeongYK,etal.Extracorporealcardiopulmonary
resuscitationinpatientswithinhospitalcardiacarrest:Acomparisonwithconventionalcardiopulmonary
resuscitation.CritCareMed.2011Jan.39(1):17.[Medline].

24.DeBackerD,BistonP,DevriendtJ,etal,fortheSOAPIIInvestigators.Comparisonofdopamineand
norepinephrineinthetreatmentofshock.NEnglJMed.2010Mar4.362(9):77989.[Medline].

25.EllenderTJ,SkinnerJC.Theuseofvasopressorsandinotropesintheemergencymedicaltreatmentof
shock.EmergMedClinNorthAm.2008Aug.26(3):75986,ix.[Medline].

26.NaplesRM,HarrisJW,GhaemmaghamiCA.Criticalcareaspectsinthemanagementofpatientswith
acutecoronarysyndromes.EmergMedClinNorthAm.2008Aug.26(3):685702,viii.[Medline].

27.FelkerGM,BenzaRL,ChandlerAB,etal,fortheOPTIMECHFInvestigators.Heartfailureetiologyand
responsetomilrinoneindecompensatedheartfailure:resultsfromtheOPTIMECHFstudy.JAmColl
Cardiol.2003Mar19.41(6):9971003.[Medline].

28.GheorghiadeM,GattisWA,KleinL.OPTIMEinCHFtrial:rethinkingtheuseofinotropesinthe
managementofworseningchronicheartfailureresultinginhospitalization.EurJHeartFail.2003Jan.5
(1):912.[Medline].

29.FuhrmannJT,SchmeisserA,SchulzeMR,WunderlichC,SchoenSP,RauwolfT,etal.Levosimendanis
superiortoenoximoneinrefractorycardiogenicshockcomplicatingacutemyocardialinfarction.CritCare
Med.2008Aug.36(8):225766.[Medline].

30.DeLucaL,ColucciWS,NieminenMS,MassieBM,GheorghiadeM.Evidencebaseduseoflevosimendan
indifferentclinicalsettings.EurHeartJ.2006Aug.27(16):190820.[Medline].

31.GruppoItalianoperloStudiodellaStreptochinasinell'InfartoMiocardico(GISSI).Effectivenessof
intravenousthrombolytictreatmentinacutemyocardialinfarction.Lancet.1986Feb22.1(8478):397402.
[Medline].

32.GruppoItalianoperloStudiodellaStreptochinasinell'InfartoMiocardico(GISSI).Longtermeffectsof
intravenousthrombolysisinacutemyocardialinfarction:finalreportoftheGISSIstudy.Lancet.1987Oct
17.2(8564):8714.[Medline].

33.SanbornTA,SleeperLA,BatesER,etal.Impactofthrombolysis,intraaorticballoonpump
counterpulsation,andtheircombinationincardiogenicshockcomplicatingacutemyocardialinfarction:a
reportfromtheSHOCKTrialRegistry.SHouldweemergentlyrevascularizeOccludedCoronariesfor
cardiogenicshocK?.JAmCollCardiol.2000Sep.36(3SupplA):11239.[Medline].

34.GarattiA,RussoC,LanfranconiM,ColomboT,BruschiG,TrunfioS,etal.Mechanicalcirculatorysupport
forcardiogenicshockcomplicatingacutemyocardialinfarction:anexperimentalandclinicalreview.ASAIO
J.2007MayJun.53(3):27887.[Medline].

35.ChengJM,denUilCA,HoeksSE,vanderEntM,JewbaliLS,vanDomburgRT,etal.Percutaneousleft
ventricularassistdevicesvs.intraaorticballoonpumpcounterpulsationfortreatmentofcardiogenicshock:
ametaanalysisofcontrolledtrials.EurHeartJ.2009Sep.30(17):21028.[Medline].

36.SjauwKD,EngstromAE,VisMM,etal.Asystematicreviewandmetaanalysisofintraaorticballoon
pumptherapyinSTelevationmyocardialinfarction:shouldwechangetheguidelines?.EurHeartJ.2009
Feb.30(4):45968.[Medline].

37.RamanathanK,FarkouhME,CosmiJE,FrenchJK,HarknessSM,DavkV,etal.Rapidcomplete
reversalofsystemichypoperfusionafterintraaorticballoonpumpcounterpulsationandsurvivalin
cardiogenicshockcomplicatinganacutemyocardialinfarction.AmHeartJ.2011Aug.162(2):26875.
[Medline].[FullText].
http://emedicine.medscape.com/article/152191treatment 12/13
11/8/2016 CardiogenicShockTreatment&Management:ApproachConsiderations,PrehospitalCare,Resuscitation,Ventilation,andPharmacologicIntervention
38.ThieleH,ZeymerU,NeumannFJ,etal.Intraaorticballoonsupportformyocardialinfarctionwith
cardiogenicshock.NEnglJMed.2012Oct4.367(14):128796.[Medline].

39.WindeckerS.Percutaneousleftventricularassistdevicesfortreatmentofpatientswithcardiogenicshock.
CurrOpinCritCare.2007Oct.13(5):5217.[Medline].

40.RoseEA,GelijnsAC,MoskowitzAJ,HeitjanDF,StevensonLW,DembitskyW,etal.Longtermuseofa
leftventricularassistdeviceforendstageheartfailure.NEnglJMed.2001Nov15.345(20):143543.
[Medline].

41.FarrarDJ,LawsonJH,LitwakP,CederwallG.ThoratecVADsystemasabridgetohearttransplantation.J
HeartTransplant.1990JulAug.9(4):41522discussion4223.[Medline].

42.DammeL,HeatleyJ,RadovancevicB.ClinicalresultswiththeHeartMateLVAD:WorldwideRegistry
update.JCongestiveHeartFailureCircSupport.2001.2:57(3).

43.HochmanJS,SleeperLA,WebbJG,SanbornTA,WhiteHD,TalleyJD,etal.Earlyrevascularizationin
acutemyocardialinfarctioncomplicatedbycardiogenicshock.SHOCKInvestigators.ShouldWe
EmergentlyRevascularizeOccludedCoronariesforCardiogenicShock.NEnglJMed.1999Aug26.
341(9):62534.[Medline].

44.AntoniucciD,ValentiR,MiglioriniA,MoschiG,TrapaniM,BuonamiciP,etal.Relationoftimeto
treatmentandmortalityinpatientswithacutemyocardialinfarctionundergoingprimarycoronary
angioplasty.AmJCardiol.2002Jun1.89(11):124852.[Medline].

45.AntmanEM,AnbeDT,ArmstrongPW,etal,fortheAmericanCollegeofCardiology,AmericanHeart
Association,etal.ACC/AHAguidelinesforthemanagementofpatientswithSTelevationmyocardial
infarctionexecutivesummary.AreportoftheAmericanCollegeofCardiology/AmericanHeartAssociation
TaskForceonPracticeGuidelines(WritingCommitteetorevisethe1999guidelinesforthemanagement
ofpatientswithacutemyocardialinfarction).JAmCollCardiol.2004Aug4.44(3):671719.[Medline].

46.HochmanJS,BolandJ,SleeperLA,PorwayM,BrinkerJ,ColJ,etal.Currentspectrumofcardiogenic
shockandeffectofearlyrevascularizationonmortality.ResultsofanInternationalRegistry.SHOCK
RegistryInvestigators.Circulation.1995Feb1.91(3):87381.[Medline].

47.JegerRV,HarknessSM,RamanathanK,etal,fortheSHOCKInvestigators.Emergencyrevascularization
inpatientswithcardiogenicshockonadmission:areportfromtheSHOCKtrialandregistry.EurHeartJ.
2006Mar.27(6):66470.[Medline].

48.HochmanJS,SleeperLA,WebbJG,etal,fortheSHOCKInvestigators.Earlyrevascularizationandlong
termsurvivalincardiogenicshockcomplicatingacutemyocardialinfarction.JAMA.2006Jun7.295
(21):25115.[Medline].

49.SlottoschI,LiakopoulosO,KuhnE,DeppeAC,SchernerM,MadershahianN,ChoiYH,WahlersT.
Outcomesafterperipheralextracorporealmembraneoxygenationtherapyforpostcardiotomycardiogenic
shock:asinglecenterexperience.JSurgRes.2013May15181(2):e4755.doi:10.1016/j.jss.2012.07.030.
Epub2012Aug1.[Medline].

50.AndersonML,PetersonED,PengSA,etal.Differencesintheprofile,treatment,andprognosisof
patientswithcardiogenicshockbymyocardialinfarctionclassification:AreportfromNCDR.CircCardiovasc
QualOutcomes.2013Nov.6(6):70815.[Medline].

51.MenonV,WhiteH,LeJemtelT,etal.Theclinicalprofileofpatientswithsuspectedcardiogenicshockdue
topredominantleftventricularfailure:areportfromtheSHOCKTrialRegistry.SHouldweemergently
revascularizeOccludedCoronariesincardiogenicshocK?.JAmCollCardiol.2000Sep.36(3suppl
A):10716.[Medline].

52.KoprivanacM,KelavaM,SolteszE,etal.Advancesintemporarymechanicalsupportfortreatmentof
cardiogenicshock.ExpertRevMedDevices.2015Nov.12(6):689702.[Medline].

53.SusenS,RauchA,VanBelleE,VincentelliA,LentingPJ.Circulatorysupportdevices:fundamental
aspectsandclinicalmanagementofbleedingandthrombosis.JThrombHaemost.2015Oct.13(10):1757
67.[Medline].

MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/152191treatment 13/13